Pain Assessment and Management in Older Adults

Chapter 16

Pain Assessment and
Management in Older Adults

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Thomas Hadjistavropoulos

The International Association for the Study of Pain
(IASP), which is the most influential group of pain
researchers and clinicians worldwide, has defined pain
as “an unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or
described in terms of such damage” (Merskey &
Bogduk, 1994, p. 209). An important element in the
definition of pain is the recognition that pain is not
only a sensory experience but also has strong emotional components. People in pain often experience
considerable psychological distress (e.g., depression)
and respond with variety of emotions (e.g., fear,
anger, disgust), thoughts, and behaviors (e.g., Hale &
Hadjistavropoulos, 1997; Romano & Turner, 1985).
These emotional, psychological and cognitive components of the pain experience are a frequent focus
of psychological intervention.
CLINICAL CRITERIA
Pain must be contrasted from nociception, which
refers to the processing of signals associated with
the stimulation of specific receptors (i.e., nociceptors) and has the potential of being experienced as
pain (Turk & Melzack, 2011). In contrast to nociception (i.e., a sensation), pain represents a perception and is associated with conscious awareness,
learning, appraisal, emotion, and ascribed meaning
(Hadjistavropoulos & Craig, 2004; Melzack &
Casey, 1968). It is important to note that IASP’s
definition of pain includes a footnote that indicates
“the inability to communicate verbally does not
negate the possibility that an individual is

experiencing pain and is in need of appropriate
pain-relieving treatment (IASP, 2012). This note is
especially important for geropsychologists working
with seniors who present with severe dementia that
is associated with limitations in ability to communicate verbally. That is, IASP recognizes that pain
can be suffered in silence or may not be clearly
expressed despite its presence.
Persistent pain is a widespread problem among
older people, with prevalence estimates ranging
from 25% to 65% of seniors living in the community
and as high as 80% of those who live in long-term
care facilities (Charlton, 2005). Pain that is of
relatively short duration is considered to be acute,
whereas pain that extends beyond the expected
period of healing is considered chronic (Turk &
Okijufi, 2001). Chronic pain often is operationalized
as pain that persists for more than 3 months
(Turk & Okijufi, 2001).
The most common clinical pain problems
involve nociceptor activity associated with the muscle, bone, joints, skin, and other connective tissue,
whereas problems associated with neuropathic pain
are caused by damage in any part of the nervous
system (i.e., nociceptive pain results from activation
of nociceptors, whereas neuropathic pain occurs
because of central nervous system problems due to
illness or injury). Common pain conditions in older
people fall under both the nociceptive (e.g., osteoarthritis of the spine and joints, other musculoskeletal
concerns) and neuropathic categories (e.g., postherpetic neuralgia, herpetic neuralgia, central poststroke pain, trigeminal neuralgia, radicular; and

http://dx.doi.org/10.1037/14459-016
APA Handbook of Clinical Geropsychology: Vol. 2. Assessment, Treatment, and Issues of Later Life,
P. A. Lichtenberg and B. T. Mast (Editors-in-Chief)
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413

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Thomas Hadjistavropoulos

referred pain secondary to degenerative disease of
the spine and painful peripheral neuropathy;
Hadjistavropoulos et al., 2007). In addition to these
problems, some conditions seen in older persons
(e.g., fibromyalgia and myofascial pain) have both
nociceptive and neuropathic elements (Hadjistavropoulos et al., 2007). Cancer pain can be nociceptive
or neuropathic depending on the type of cancer.
Patients with chronic pain conditions sometimes
have been classified using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM–IV–TR; American Psychiatric
Association, 2000), wherein a pain condition could
be coded under Axis III as a pain disorder associated
with a medical condition. In Axis I, relevant categories for certain people with chronic pain included
somatization disorder (a polysymptom disorder that
cannot be explained by physical factors), pain disorder associated with psychological factors, and pain
disorder associated with both psychological factors
and a medical condition. In general, pain disorder is
a condition in which psychological factors are
thought to play a major role in its causation and
maintenance and nonpsychological factors are
believed to play a minimal role. In Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition
(DSM–5; American Psychiatric Association, 2013),
however, somatic symptom disorder was replaced
by somatization disorder, undifferentiated somatoform disorder, and pain disorder, although some
people with pain can still be diagnosed with psychological factors affecting other medical conditions.
The DSM–5 somatic symptom disorder is characterized by somatic symptoms that cause significant disruption, excessive thoughts, feelings, and behaviors
associated with such symptoms and chronicity. This
change in the DSM–5 represents better recognition
that the physical and psychological elements of the
pain experience are well integrated. In other words,
the DSM–5 appropriately does not encourage separate estimation of the contribution of physical
versus psychological factors in pain.
Psychological comorbidities commonly are
seen in pain patients. Chronic pain in older adults,
for example, often is comorbid with depression (Bonnewyn et al., 2009) and higher levels of anxiety have
been associated with more postoperative disability
414

days for surgical patients (Taenzer, Melzack, & Jeans,
1986). Higher rates of anxiety also have been observed
in long-term care residents experiencing pain (Casten,
Parmelee, Kleban, Lawton, & Katz, 1995). Moreover,
sleep difficulties are common in older chronic pain
samples (Chen, Hayman, Shmerling, Bean, & Leveille,
2011) and often are due, at least in part, to physical
discomfort. Given such comorbidities, it is not surprising that older people with chronic pain have an
increased likelihood of seeking mental health services
(Bonnewyn et al., 2009). Pain also can prevent older
people from engaging in beneficial physical activity,
which may lead to increased rates of obesity and associated cardiovascular risk in chronic pain patients
(e.g., McVinnie, 2013).
MAJOR THEORIES OF PAIN
Starting in the 17th century with Descartes’ work,
specificity theories of pain developed. Such theories
assumed a direct pain pathway from the location of
tissue damage to the brain as well as a one-to-one
correspondence between pain and tissue damage.
In other words, the implication of these theories is
that the greater the tissue damage, the greater the
pain and that tissue damage is necessary for pain to
be experienced. Over the years, the field evolved and
new theories emerged but no theory proved to be satisfactory and capable of accounting for a wide range
of phenomena, including observations that the
degree of tissue damage experienced and the degree
of pain do not always correspond, until Melzack and
Wall (1965) proposed the gate control theory of pain.
According to the theory, which has received considerable support from basic science, clinical, and psychological research perspectives, the spinal cord has a
gating mechanism at the level of substantial gelatinosa. As Melzack and Katz (2004) explained, nerve
impulses are transmitted from afferent fibers to spinal
cord transmission cells and are modulated by the gating mechanism in the dorsal horn of the spinal cord.
This gating mechanism is affected by activity of large
diameter fibers (representing sensory neuronal pathways) and small diameter fibers (i.e., pain pathway
fibers). Specifically activity of the large diameter
fibers tends to close the gate by inhibiting competing
transmission of small-diameter fibers. As a practical

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Pain Assessment and Management in Older Adults

example, rubbing a painful area often helps improve
the pain because rubbing results in activation of the
large-diameter fibers thought to inhibit nociceptive
transmission. The large- and small-diameter fibers
synapse on projection cells, which reach the brain
through the spinothalamic tract. When output of the
transmission cells reaches a critical threshold, it activates the neural areas that affect the complex patterns
of pain experience and expression. Critical to the gate
control theory is an understanding that descending
cortical input (e.g., cognitive processes such as attention) can facilitate or inhibit the transmission of nociceptive messages. Melzack and Wall’s description of
the process through which cortical input affects the
gating mechanism provides a physiological explanation for the importance of psychological processes in
the experience of pain and reinforces arguments for
the use of psychological intervention in pain management. The gate control theory has been supplemented by the more recent, Neuromatrix model of
pain that was developed to explain phenomena, such
as phantom limb pain. This model (Melzack, 2001,
2005) explains how pain can be generated by neural
activity through a network of brain structures and
that the network can produce pain even in the
absence of external sensory stimulation.
Based on the fundamental assertion of the gate
control theory that pain can be affected by psychological and cognitive processes, a variety of biopsychosocial models of pain have been developed. These
models are consistent with the gate control theory
but provide more detail on the role of psychological
factors. Although various models exist, a few key
models are emphasized in the following sections.

The Operant Model
The operant model (e.g., Fordyce, 1976; Fordyce,
Shelton, & Dundore, 1982) focuses on the consequences of pain behavior and the role of such consequences in its maintenance and further development.
According to this viewpoint, if maladaptive pain
behavior (e.g., excessive complaining) is reinforced
(e.g., with attention), it would become more likely to
be maintained or increased in frequency. By the same
token, if avoidance of work or activity are reinforced
(e.g., by temporarily reducing pain or by reduced
stressful responsibilities), they may persist and

become maladaptive. In the case of an older person
who is widowed and has pain, for example, it is possible that frequent pain complaints will be reinforced
by increased family visitation. That is not to imply in
any way that social support from family is not desirable. On the contrary: Social support is desirable. In
situations in which complaining becomes excessive,
however, it can create relationship tension. Moreover, where social support becomes excessive, to the
point that it is solicitous, it can have negative consequences (Boothby, Thorn, Overduin, & Ward, 2004;
McCracken, 2005; Paulsen & Altmaier, 1995) and
encourage inactivity and avoidance of beneficial
activity. As an example of solicitous support, consider a person who is actively discouraged from completing even very basic and safe physical tasks while
relatives offer an excessive amount of assistance
(e.g., “Don’t get up! I will do this for you”). In such
an instance, solicitous support may be contributing
to deconditioning, which could interfere with recovery from injury. Although some laboratory support
for the operant model exists, a criticism is that it does
not account for the important role of appraisals in the
pain experience (Sharp, 2001).

Fear Avoidance Model
The fear avoidance model (Vlaeyen & Linton, 2000)
of pain incorporates elements of both classical and
operant conditioning. The assumption is that anxiety is often a component of pain. As such, movement
or activity that is associated with pain can become a
conditioned stimulus for fear and anxiety. In turn, if
avoidance of that activity results in reduced pain,
avoidance is reinforced and may become frequent
and, sometimes, excessive. According to the model,
this process can be further strengthened with catastrophic thoughts about pain and its consequences.
The model would predict that an older person, who
excessively avoids activity as a means of preventing
pain, may become stiff and deconditioned. Such
deconditioning could interfere with the ability to
overcome certain types of pain problems; it also can
worsen them and sometimes can increase the risk of
injurious falls. Generally, clinical research investigating aspects of the fear avoidance model has
yielded support for many aspects of the model, but
the identified effects are generally small (Moseley,
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Thomas Hadjistavropoulos

2011). As such, excessive avoidance may be best
construed as one of many factors contributing to
pain and disability (Moseley, 2011). Treatments
designed to overcome excessive avoidance of activity
have been developed with some success reported
(e.g., George, Wittmer, Fillingim, & Robinson,
2010). Such treatments tend to involve in vivo exposure to various physical tasks with the aim of overcoming pain-related anxiety about performing these
tasks (e.g., Boersma et al., 2004).

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Cognitive–Behavioral Theory of Pain
According to Skinner, Wilson, and Turk (2012) the
five key assumptions of the cognitive–behavioral theory
of pain (e.g., Sharp, 2001; Turk, Meichenbaum, &
Genest, 1987) are as follows:
1. People are active processors of information
rather than passive recipients of environmental
influence. That is, they interpret their experiences and make sense of them.
2. Beliefs, appraisals, attributions, and expectations
can elicit and influence both affect and physiological arousal, which in turn can influence
behavior.
3. Behavior is determined reciprocally by both the
environment and the person.
4. People may have learned maladaptive ways of
feeling, thinking, and responding.
5. People are instrumental in the development and
maintenance of maladaptive thoughts and, as
such, they should be considered active agents of
change for the purposes of clinical intervention.
Examples of maladaptive views in the context
of the older adult may include beliefs that pain is
a natural part of old age and simply should be
endured. Such a belief may make the older person
less likely to seek appropriate treatment and pain
management solutions. Although pain may be common in old age, it is thought to be related to pathology and not simply aging. Pathology should be
treated and pain should be managed irrespective of
a person’s age. Other counterproductive beliefs may
relate to inaccurate assumptions that pain levels in
an older person usually cannot be improved with
intervention. Cognitive–behavioral approaches to
pain often adopt broad perspectives that incorporate
416

operant and fear avoidance models of pain. For
example, operant views are incorporated through
the recognition of environmental influences on
behavior (see the second key assumption).
A considerable body of research has led to support for the cognitive–behavioral formulation of the
pain experience (e.g., Hadjistavropoulos, Craig,
et al., 2011). For example, catastrophic thinking
about pain is a well-established risk factor in the
development of disability and chronicity (Haythornthwaite, Clark, Pappagallo, & Raja, 2003; Linton,
2005; Picavet, Vlaeyen, & Schouten, 2002; Sullivan,
Feuerstein, Gatchel, Linton, & Pransky, 2005) and
catastrophizing goes hand in hand with pain intensity in older people (Ruscheweyh et al., 2011).
Moreover, a variety of effective interventions based
on this model have been developed (Day, Thorn, &
Burns, 2012).
ASSESSMENT AND INTERVENTION
Pain is a multidimensional experience that is most
likely to be assessed and treated effectively using an
interdisciplinary (i.e., combinations of approaches,
such as physical therapy, psychological intervention,
medication) rather than a single-modality approach
(e.g., only medication or only cognitive–behavioral
therapy [CBT]). With most types of persistent pain,
medical, nursing, physical therapy, occupational
therapy, psychological, and other expertise may be
needed. Although a psychologist may be well
equipped to assess the intensity and psychological
sequelae of pain, physiological, medical, and physical processes related to pain must be assessed by
other professionals. With respect to treatment, a
combination of physical therapy, pharmacological,
occupational therapy, and psychological regiments
may work best. As such, the functioning of an effective interdisciplinary team, for both treatment and
assessment, is of critical importance. In instances in
which psychologists who work in the community
are not part of a formal team, it would be critical to
establish open pathways of communication with the
treating physician and other health professionals to
optimize coordinated care.
Psychologists have been involved in the assessment and treatment of older pain patients at a variety

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Pain Assessment and Management in Older Adults

of settings. For example, they provide treatment and
assessment services at rehabilitation units, pain clinics, and private practice (e.g., seeing an older adult
who is receiving insurance compensation following
a motor vehicle accident). Although older adults
traditionally have been underrepresented in pain
clinics, specialized units for treating pain in older
people have begun to develop. For instance, in Montreal, the McGill University Health Centre operates
a geriatric pain clinic that includes a psychologist
(http://www.mcgill.ca/paincentre/treatments). In
long-term care, geropsychologists have been
involved as consultants in the assessment of pain
(e.g., Ghandehari et al., 2013) as well as in the management of psychological states (e.g., depression;
Teri, Logsdon, Uomoto, & McCurry, 1997) that can
sometimes result from pain. Although information
about the role of psychologists in the pain assessment and management of older adults in primary
care, home care, and acute care is extremely limited,
psychologists have a key role to play as consultants
in the facilitation of the assessment and treatment of
older pain patients in such settings.

Exhibit 16.1
Central Pain Assessment Domains
■■

■■

■■

■■

■■

■■
■■

Assessment
A detailed international interdisciplinary statement
on pain assessment in older people (Hadjistavropoulos et al., 2007) outlines the benefits of intedisciplinarity and discusses the importance of considering
the effects of biological factors, disease, disuse,
and environmental factors affecting functional outcomes. A physical evaluation by a qualified health
professional (e.g., a physician) is of utmost importance. Under ideal circumstances, a functional
evaluation also will be conducted (usually by a
physiotherapist), as will an assessment of emotional
functioning (e.g., by a psychologist). Moreover, a
comprehensive pain assessment will include a
detailed history, which can be the most important
initial source of information about the pain and its
causes. The history will establish a time frame for
the pain, antecedents and consequences, reactions
of others, comorbidities, treatments, expectations
about outcomes, lifestyle factors, social history,
coping efforts, psychological concerns, substance
use, and other related areas (see Exhibit 16.1). Interviews with family members are helpful (e.g., family

■■

■■
■■
■■

Description of the pain and any related presenting issues
(e.g., nature and intensity of pain, inability
to perform the duties of one’s occupation due to pain)
Establishment of a timeframe for the pain and
its course (e.g., onset, precipitants, fluctuation
over time, possible contributors to fluctuations)
Antecedents of pain flare-ups
■■ Examples of physical antecedents: excessive physical
activity, specific movements
■■ Examples of psychological or situational antecedents:
general stress, insomnia
Consequences of pain flare-ups
■■ Example of physical consequences: inability to engage
in certain movements
■■ Behavioural, psychological, and social: going for
massage therapy, irritability, others offering to help,
changes in routines, changes in mood
Comorbidities
■■ Example of physical comorbidities: coronary heart
disease
■■ Examples of psychological comorbidities: major
depression, posttraumatic stress disorder
Litigation and compensation issues
Coping and pain management efforts
■■ Examples of physical coping strategies: using over-the
counter medication, application of heat or cold
■■ Examples of psychosocial coping strategies: distraction, trying to stay busy with friends, coping
self-statements
History and lifestyle factors
■■ Personal history
■■ Current stressors
■■ Educational and occupational history
■■ Brief health history
■■ Current social supports
■■ Hobbies, exercise habits, health-promoting behaviors
■■ Substance use
■■ Goals and plans for the future
Past and current treatment history
Past history of psychological problems
Client goals, concerns, and expectations about therapy

Note. This list of clinical interview domains is not
meant to be exhaustive but rather is intended to highlight key domains that typically are covered during
an interview with a pain patient.

members often can serve as collaborators in the
treatment) but become critical in cases of seniors
who have limited ability to communicate because of
dementia.
417

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Thomas Hadjistavropoulos

Pain assessment with people without severe
limitations in ability to communicate.  Pain cannot be directly observed and typically is assessed
using self-report procedures, although the observation of pain-related behavior is also important. In
addition to a thorough clinical interview, psychologists typically will use a variety of assessment tools
to evaluate an older person with chronic pain. Many
assessment tools that have been used by psychologists, however, have psychometric properties that
have not been investigated adequately in the context
of the older adult. As such, psychologists must be
cognizant of the potential limitations of this and aim
to use tools that have been validated specifically for
older people. Functional analysis of pain and behavior would also be important to conduct with a focus
on identifying important antecedents (e.g., stress)
and consequences (e.g., anger or irritability, reactions of others) of pain exacerbations. Such antecedents and consequences can become the focus
of treatment.
For patients who are able to participate in an
assessment that involves self-report (as opposed to
patients with severe cognitive impairments) a variety
of procedures can be used. Simple self-reports of pain
can be obtained using numeric rating scales (0–10;
Gagliese, Weizbliz, Ellis, & Chan, 2005; Weiner,
Peterson, Logue, & Keefe, 1998) or verbal rating
scales in which verbal descriptors to describe pain
intensity are used (e.g., using words such as mild,
severe, very severe; Gagliese & Katz, 2003; Herr, Spratt,
Mobily, & Richardson, 2004). The use of horizontal
analogue scales (i.e., a 10 cm line anchored by the
polar opposites pain and no pain, which involve the
older person marking an × on the part of the line that
represents his or her pain intensity) is not recommended because some researchers have identified
unusually high numbers of unscorable responses
among older adults (Gauthier & Gagliese, 2011). On
the other hand, there are reports that horizontal visual
analogue scales have been used with reasonable success
in some samples of seniors (e.g., Scherder & Bouma,
2000). Nonetheless, numeric and verbal rating scales
may be the simplest and probably most recommended basic pain self-report procedure.
When using self-report procedures, including
reports with accommodations for patients’ sensory
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deficits (e.g., use of large fonts), questions can focus
on current pain, average pain over the past day, and
average pain over the past week. Information concerning fluctuations of the pain problem also can be
collected. Specialized tools to assess neuropathic
pain, such as the Neuropathic Pain Symptom Inventory (Bouhassira et al., 2004), are available These
tools can help clinicians and interdisciplinary teams
differentiate a neuropathic from a nociceptive pain
problem as the two have distinct qualities. For example, neuropathic pain is more likely to be described
as burning or as having electric-like qualities.
Some tools for evaluating coping strategies,
such as the Coping Strategies Questionnaire (CSQ;
Rosenstiel & Keefe, 1983), have been validated with
older adults (e.g., Felton & Revenson, 1984; Keefe
et al., 1987). Moreover, a variety of general psychological tools, such as the Satisfaction With Life Scale
(Pavot & Diener, 1993), the NEO Personality Inventory (Costa & McCrae, 1992; Costa et al., 1986), and
the Hospital Anxiety and Depression Scale (Spinhoven et al., 1997; Zigmond & Snaith, 1983) also
have been validated with seniors and may be useful
for the assessment of psychological functioning in
chronic pain patients (e.g., Costa & McCrae, 1992).
The Multidimensional Pain Inventory (MPI;
Kerns, Turk, & Rudy, 1985), a 61-item tool, allows
for assessment of several dimensions beyond pain
intensity and interference as it incorporates appraisals, such as perceived life control as well as indexes
of perceived social support and affective distress.
The tool, which has good psychometric properties
with younger persons, has been used with success
with older adults but more study with older individuals is needed before one can be confident about its
properties with this population (Hadjistavropoulos
et al., 2007; Kerns et al., 1985).
In cases in which a brief battery (10–15 min) is
needed for pain assessment in older adults, Hadjistavropoulos et al. (2007) recommended use of the
Brief Pain Inventory (BPI; Cleeland & Ryan, 1994)
combined with the Short-Form of the McGill Pain
Questionnaire (MPQ-SF; Melzack, 1975). The former tool consists of 11 items and assesses selfreported pain intensity and self-reported interference
with function in a variety of domains (e.g., physical,
psychological, and recreational). Because the BPI

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Pain Assessment and Management in Older Adults

includes questions about mood and enjoyment of
life, to some extent, it screens for the psychological
impact of pain. Initial evidence suggests that the BPI
is valid, sensitive, and reliable when used with older
people (see Gauthier & Gagliese, 2011). The MPQSF, which consists of 15 pain quality words scored
on a Likert severity scale in addition to two general
items about current pain intensity and sensation,
evaluates specific qualities of the pain (e.g., affective
and sensory). The tool has been shown to have satisfactory test–retest reliability as well as high concurrent validity and sensitivity when used with older
people (see Gauthier & Gagliese, 2011). A thorough
discussion of pain assessment is included in Hadjistavropoulos et al. (2007).
Pain assessment in people with dementia. 
A special challenge facing the clinical geropsychologist relates to the assessment of pain in older people
who have serious limitations in ability to communicate because of dementia. Pain problems in these
populations often are missed by health care staff
(because of limited ability to self-report) and can
lead to behavioral disturbance, which often is misattributed to possible psychiatric conditions. As a
result, patients with severe dementia and pain often
are treated with psychotropic rather than analgesic
medications (e.g., Balfour & O’Rourke, 2003). This
is an important concern not only because the pain
is not treated adequately but also because many
psychotropic medications have been show to hasten
death in seniors (Ballard et al., 2009) often through
increased risk of stroke and of falls (Laredo et al.,
2011; Lindsey, 2009).
Given the widespread undertreatment of pain
among patients with dementia (Ferrell et al.,
2001; Horgas, Nichols, Schapson, & Vietes, 2007;
Jakobsson, Rahm Hallberg, & Westergren, 2004;
Kaasalainen et al., 1998; Martin, Williams,
Hadjistavropoulos, Hadjistavropoulos, & MacLean,
2005; Morrison & Sui, 2000; Reynolds, Hanson,
DeVellis, Henderson, & Steinhauser, 2008; Robinson, 2007; Won et al., 2004), effective pain assessment becomes extremely important. Research has
demonstrated that people with mild to moderate
dementia often are able to self-report pain in a
reliable and valid fashion (Hadjistavropoulos,

Breau, & Craig, 2011) and that simple self-report
tools such as numeric (0–10) and verbal rating
scales can be used effectively. One horizontal visual
analogue scale that has been used with success in
people with mild to moderate dementia (Hadjistavropoulos et al., 1997) is the colored visual analogue
scale (CAS; McGrath et al., 1996). The CAS typically is made of plastic and has rectangular shape
(like ruler). The front of the scale shows the words
most pain at the top and no pain at the bottom.
Moreover, the color of the scale starts as a white to
light pink at the bottom and becomes progressively
more red as it approaches the top of the scale. The
patient uses a plastic glide, that moves along the
scale, to indicate his or her level of pain. The back
of the scale includes numbers (0–10) that can be
recorded by the clinician and signify pain intensity
(10 = glide at the top of the scale; 0 = glide at the
very top of the scale). Scherder and Bouma (2000)
developed a quick protocol that allows clinicians to
evaluate the patient’s ability to comprehend and use
the CAS before the pain assessment (e.g., the patient
is asked to point to the scale, the plastic glide,
where the glide should be placed if there is no pain).
Some clinicians have used the Faces Pain Scale
(FPS; Bieri, Reeve, Champion, Addicoat, & Ziegler,
1990) to evaluate pain intensity in seniors with
dementia. The FPS consists of a series of drawings of
faces expressing increasing distress and the patient
is asked to select the face that best corresponds to
his or her pain. Compared with other pain intensity
tools, however, this scale sometimes correlates less
positively with other pain intensity scales and
requires abstract reasoning, which makes its use difficult for many older people with cognitive impairment (Hadjistavropoulos et al., 2007). Scherder and
Van Manen (2005), for example, demonstrated that
the majority of seniors with dementia who were able
to understand the CAS also were unable to understand the FPS. From a clinical standpoint, it is also
noted that some seniors may select a face that corresponds to negative (or positive) affect that they may
be experiencing rather than a face corresponding to
their level of pain. Such a selection would confound
interpretation of the scale.
As a rule of thumb, based on the research literature
(Weiner, Peterson, Lad, McConnell, & Keefe, 1999;
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Thomas Hadjistavropoulos

Chibnall & Tait, 2001), it has been suggested that
older adults with Mini-Mental Status Examination
(MMSE; Folstein, Folstein, & McHugh, 1975) scores
of more than 18 typically can self-report pain whereas
those with MMSE scores of 13 or lower tend to have
considerable difficulty (Hadjistavropoulos, 2005). No
cognitive test, however, can determine with certainty
whether a senior with dementia can self-report pain.
As such, it is recommended that self-report of pain be
attempted in all instances.
As the dementia progresses and language abilities
deteriorate, clinicians are faced with the challenge of
evaluating pain among patients who cannot selfreport their experience. In recent years, a considerable amount of research has been conducted on the
development and evaluation of observational tools
designed to assess pain in people with dementia
(e.g., Fuchs-Lacelle & Hadjistavropoulos, 2004;
Villanueva, Smith, Erickson, Lee, & Singer, 2003;
Warden, Hurley, & Volicer, 2003).
One of the most researched approaches to the
evaluation of pain in people with severe dementia
who reside in long-term care facilities is the Pain
Assessment Checklist for Seniors with Limited Ability
to Communicate (PACSLAC; Fuchs-Lacelle &
Hadjistavropoulos, 2004). The PACSLAC consists of
60 pain-related behaviors (e.g., wincing, pulling away,
grimacing, guarding sore area) that can be observed
by health care personnel. Research has demonstrated
that the PACSLAC has strong psychometric properties (Lints-Martindale, Hadjistavropoulos, Lix, &
Thorpe, 2012), can improve clinical outcomes in
long-term care facilities (Fuchs-Lacelle, Hadjistavropoulos, & Lix, 2008) and is considered to be clinically useful by front-line health care staff (Zwakhalen,
Hamers, & Berger, 2006). Moreover, it comprehensively covers all of the pain assessment domains
(i.e., facial expressions, verbalizations and vocalizations, body movements, changes in activity patterns
and routines, interpersonal interactions, and mental
status changes) deemed to be important by the American Geriatrics Society (AGS Panel on Persistent Pain
in Older Persons, 2002). More recently, a revised
shorter (31 item) version of the PACSLAC, the PACSLAC-II, was developed with initial validation research
demonstrating better ability to discriminate pain
from nonpain states than the PACSLAC and other
420

commonly used tools (Chan, Hadjistavropoulos,
Lints, & Martindale, 2014). The PACSLAC-II
retained coverage of all observational pain assessment
domains deemed to be important by the AGS.
Examples of briefer pain assessment tools that
have been developed for seniors with dementia and
have satisfactory psychometric properties, include,
but are not limited to, the Pain Assessment in
Advanced Dementia (PAINAD), which consists of
five items (Warden et al., 2003), and the Doloplus-2, which consists of 10 items (Wary, 1999). In a
study that involved, a clinical comparison of the
PACSLAC, the PAINAD, and the Doloplus-2, nursing staff rated the PACSLAC as the most clinically
useful of the three tools (Zwakhalen et al., 2006).
Although this issue has not been investigated systematically, all of the observational pain tools
reviewed here are easy to administer and usually are
completed by nursing and special care aide personnel. It is important to note that there is no definitive
consensus as to which pain assessment tool is best
for seniors with severe dementia. Clinicians should
review the literature and select the tool that they
consider most appropriate for their clients.
Selecting an appropriate assessment tool is only
the beginning of a successful pain assessment.
Hadjistavropoulos et al. (2007), Herr et al. (2006),
and others have proposed several steps for effective
pain assessment. Rather than using cutoff scores to
signify pain or its absence, it has been argued that an
individualized approach to assessment be used because
dementia represents a diverse set of conditions and
types of damage to the brain. As a result of the varied
pathology, responses to pain differ from person to
person. Given this type of diversity, using a single
cutoff score may not be indicated. Instead, an individualized approach to assessment can be used wherein
pain is assessed on a regular basis and the clinician
considers unusual fluctuations from the patient’s normal score as possibly signifying changes in pain levels. Such fluctuations then would need to be followed
up with physical examinations and appropriate
treatment. Exhibit 16.2 shows a general approach to
pain assessment in dementia. Figure 16.1 shows a
diary (Misson, Savoie, Aubin, Hadjistavropoulos, &
Verreault, 2011) involving use of the PACSLAC
and how the information gathered can be used.

Pain Assessment and Management in Older Adults

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EXHIBIT 16.2
Guidelines for Assessing Pain With Seniors Who Have
Cognitive Impairments
General guidelines
1. Determine whether Mini-Mental Status Examination scores are available or can be obtained. This would facilitate
determination of patient ability to provide valid self-report.
2. Always attempt self-report regardless of level of cognitive functioning.
3. Baseline scores should be collected for each individual (ideally on a regular basis, which would allow for the examination of
unusual changes from the person’s typical pattern of scores).
4. Patient history and physical examination results should be taken into consideration.
5. If assessments are to be repeated over time, assessment conditions should be kept constant (e.g., use the same assessment
tool, use the same assessor where possible and conduct pain assessment during similar situations).
6. Pain assessment results should be used to evaluate the efficacy of pain management interventions.
7. Knowledgeable informants (e.g., caregivers) should be asked about typical pain behaviors of the individual.
8. Other aspects of the pain experience should also be evaluated including environmental factors, psychological functioning and
social environment.
Recommendations specific to self-report measures
1. Use of synonyms when asking about the pain experience (e.g., hurt, aching) will facilitate the self-report of some patients
who have limitations in ability to communicate verbally.
2. Self-report scales should be modified to account for any sensory deficits that occur with aging (e.g., poor vision, hearing
difficulties).
3. Use self-report tools that have been found to be most valid among seniors (e.g., the Numeric Rating Scales, Verbal Rating
Scales).
4. Use of horizontal visual analogue scales should be avoided as some investigators have found unusually high numbers of
unscorable responses among seniors.
Recommendations specific to observational measures
1. Examples of observational tools that have been shown to be reliable and valid for use in this population include the Pain
Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) and Doloplus-2. Nonetheless, clinicians
should always exercise caution when using these measures because they are relatively new and research is continuing.
2. When assessing pain in acute-care settings tools that primarily focus on evaluation of change over time should be avoided.
3. Observational assessments during movement-based tasks would be more likely to lead to the identification of underlying pain
problems than assessments during rest.
4. Some pain assessment tools, such as the PACSLAC, do not have specific cutoff scores because of recognition of tremendous
individual differences among people with severe dementia. Instead, it is recommended that pain be assessed on a regular
basis (establishing baseline scores for each patient) with the clinician observing score changes over time.
5. Examination of pain assessment scores before and after the administration of analgesics is likely to facilitate pain
assessment.
6. Some of the symptoms of delirium (which is seen frequently in long-term care) overlap with certain behavioral
manifestations of uncontrolled pain (e.g., behavioral disturbance). Clinicians assessing patients with delirium should be
aware of this. On the positive side, delirium tends to be a transient state, and pain assessment, which can be repeated or
conducted when the patient is not delirious, is more likely to lead to valid results. Note also that pain can cause delirium, and
clinicians should be astute to avoid missing pain problems among patients with delirium.
7. Observational pain assessment tools are screening instruments only and cannot be taken to represent definitive indicators
of pain. Sometimes, they may suggest the presence of pain when pain is not present, and other times they may fail to
identify pain.
Outcomes of interest
In addition to improved scores on various assessment tools, evidence of more effective pain management can be observed in
such areas as greater participation in activities, improved sleep, reduced behavioral disturbance, improved ability to ambulate,
and improved social interactions.

Note. Many of these recommendations are from Hadjistavropoulos et al. (2007) and Herr et al. (2006). Copyright
by Thomas Hadjistavropoulos. Reprinted with permission.

421

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Thomas Hadjistavropoulos

Although this section focused primarily on
assessment of pain intensity, psychosocial aspects of
the pain experience also should be considered
(e.g., Does the patient have visitors who would distract him or her from the pain experience? Is he or
she engaging in a sufficient number of pleasurable
activities such as accompanied walks or visits to the
courtyard?). In patients with severe dementia, it is
often difficult to separate depression and other
conditions that may be caused or exacerbated by
chronic pain from direct manifestations of pain.
Although a limited number of tools to assess emotional states and quality of life, often based largely
on caregiver reports, are available (e.g., the Cornell
Scale for Depression in Dementia; Alexopoulos,
Abrams, Young, & Shamoian, 1998), such tools tend
to assess for the presence or absence of symptoms,
such as sleep disturbance and irritability. The difficulty with use of such tools with patients suffering
from pain relates to the challenges associated with
distinguishing symptoms that are the direct consequence of pain (e.g., pain-related sleep interference)
from symptoms that are the result of an emotional
disturbance (e.g., insomnia due to an emotional
cause). Given this difficulty, the treatment team may
try to address the suspected pain problem and determine whether the pain treatment leads to an improvement in the symptoms that overlap with emotional
disturbance. If emotional disturbance persists, despite
appropriate and thorough pain treatment, it would be
necessary to investigate further possible contributors
to such disturbance besides pain.
Controversies regarding assessment.  Despite the
clear identification of the psychological factors in
pain, one frequently encounters disagreements about
the nature of the experience with contested issues
including willingness to dismiss the importance of
patient thoughts, feelings, the social environment and
the extent to which psychological factors are relevant
to the assessment and treatment of pain and injury
(for a discussion, see Craig & Hadjistavropoulos,
2004). The biocentric training of many health professionals can make appreciation of psychological
elements of the pain experience difficult. As such, it
is not uncommon for patients to receive the message
that because nothing wrong is physically apparent,
422

their pain must be caused by psychological factors.
Pain, however, has physical, emotional, and cognitive
components that tend to be intertwined, difficult to
separate, and affect outcomes. As such, it is critical
for psychologists to educate other professionals about
the psychological components of pain through inservice continuing education, case conferences, and
related discussion.
A second point of controversy is the consideration of self-report as the gold standard in pain
assessment. In fact, it has been demonstrated that
both self-reports and nonverbal pain expressions are
critical in understanding pain as they tap different
aspects of the pain experience (Hadjistavropoulos,
Craig, et al., 2011; Labus, Keefe, & Jensen, 2003).
Self-report can be influenced by both situational
demand characteristics and relies on cognitive executive mediation, whereas nonverbal pain expressions usually tap more immediate, reflexive aspects
of the pain experience. An added related concern
from a geropsychologist’s standpoint is that
although self-report is a critical component of the
assessment of pain, it is not particularly useful when
assessing individuals with severe cognitive impairments and limitations in ability to communicate.
The suggestion that pain is “whatever the patient
says it is” (e.g., McCaffery, 1968), although it has a
well-intentioned person-centered focus, can result
in an underemphasis of adequate assessment within
the population of people with severe dementia.
Equally controversial within various organizations caring for older people (e.g., long-term care
facilities that often are referred to as “nursing
homes”) are questions related to how much of their
limited funding and resources should be dedicated
to adequate pain assessment. Systematic observational and psychological assessment of the pain
patient often is viewed as a luxury. As a result,
assessment practices, related to pain in older adults,
often leave a lot to be desired (Hadjistavropoulos,
Marchildon, et al., 2009). Perhaps because of the
costs of continuing pain education and time constraints, for example, observational pain tools often
are not used for seniors with severe limitations in
ability to communicate due to dementia, and
research has identified significant education gaps
related to pain assessment and management among

Pain Assessment and Management in Older Adults

PACSLAC PAIN DIARY

Patient NAME: Mr. Case Example
COMMENTS

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An increase in scores was noted
starting at the 8th of March. The
cause of pain was thoroughly
examined on May 9 and 10
leading to the conclusion that
the resident was suffering from
a tooth abscess. Antibiotic
treatment commenced on May
10 leading to a gradual
reduction in pain over the next
several days.
An increased pain on March 25
was attributed to a tooth
extraction that took place on
that day. The pain was treated
with analgesic medication for
several days as necessary.

FIGURE 16.1.  Use of a pain diary for the Pain Assessment Checklist for Seniors With Limited Ability to
Communicate (PACSLAC). The vertical axis represents scores on the PACLAC (range 0–60). See Misson et al., 2011.

long-term care staff and other health care providers
(Martin et al., 2005; Zwakhalen, Hamers, Peijnenburg, & Berger, 2007). Specific cost-effective pain
assessment models suitable for long-term care facilities (Hadjistavropoulos, Marchildon, et al., 2009) as
well as for community settings (Hadjistavropoulos
et al., 2007) have been proposed but have not been
implemented on a large-scale basis probably because
(although often financially feasible) they still have
resource implications. For example, it has been suggested that for effective and systematic pain assessment to occur, long-term care facilities would need
to dedicate a nursing position to pain assessment

and management (e.g., Hadjistavropoulos, Marchildon, et al. 2009).
Insufficient pain education for health care staff
(e.g., Watt-Watson et al., 2009) is a problem that
extends outside long-term care (e.g., acute care,
home care, and rehabilitation settings). The lack of
familiarity with specialized assessment tools for
seniors, and especially seniors with dementia, also is
observed in primary care, home care, acute care, and
rehabilitation facilities.
Finally, although much research has been conducted on pain assessment, there are no perfect
tools. Responses to both self-report tools and
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Thomas Hadjistavropoulos

observational procedures (which sometimes rely on
the interpretation of ambiguous behavioral signals)
are far from perfect. The limitations of assessment
tools also result in professionals (and often insurance organizations) to sometimes question the veracity of patient complaints and to attribute such
complaints to factors such as secondary gain or psychiatric disturbance. De Ruderre, Goubert, Vervoort,
Kappesser, and Crombez (2013) demonstrated that
even raising the possibility of deception within a
compensation system in very general terms can have
a negative impact on how individual patients are perceived. This unfortunate situation can have implications for the nature of the relationship between
patient and clinician (Hadjistavropoulos, 2013).
Although older adults often are retired and returning
to work may not be an issue for them, they still may
be dealing with insurance organizations following
various accidents (e.g., motor vehicle). Consequently, many questions about insurance compensation and funding of treatment can be raised.

Client–Provider Issues Related
to Intervention
Expectancies regarding intervention and outcome. 
Psychological interventions with seniors who reside
in the community.  The absence of familiarity with
both the role of psychological processes in the pain
experience and the potential impact of psychological
interventions may lead an older person to not have
positive expectations about the outcome of psychological therapy. One of the most frequent issues
encountered when a person with pain is referred to
a psychologist involves questioning the reason for
the referral. Clients often will say something like,
“I am not sure why I have been referred to you. I’m
not crazy.” Although the goal of a pain management psychologist may be twofold (i.e., to improve
the pain experienced, and to enhance one’s quality of life despite the pain), it often is advisable to
emphasize the second goal when providing an initial
rationale for treatment (i.e., that a person’s quality of life can be improved despite the pain) with
skeptical clients. Client skepticism tends to be based
on widely accepted beliefs, consistent with early
biomedical conceptualizations, that pain is purely a
424

physical experience and that psychological factors
are relevant only for individuals who suffer pain
as a result of a mental disorder. Once a rapport is
established, the pain intensity reduction goal can be
introduced in more detail, especially after the client
understands the role of psychological influences in
the pain experience.
Evidence suggests that prevalent myths about
pain in old age also can affect expectations and
treatment or referral seeking of both older people
and health professionals (Martin et al., 2005). One
of the most prevalent myths is that pain is a natural
consequence of old age and needs to be endured.
As indicated, although pain is frequent in old age, it
is not natural and is the result of pathology. If we
think of pain as natural, we would be less inclined
to treat it. Educating both seniors and those who
provide care to older people that pain can and
should be managed (and improve quality of life),
despite a person’s age, is important. Older adults
often tend to be stoic about their pain experience
(Yong, Gibson, Horne, & Helme, 2001). Some older
people may believe that discussing their pain might
lead them to be perceived as complainers or to fear
that family and others might pressure them to
reduce independence, possibly by moving into an
assisted living arrangement. It would be important
for the clinical geropsychologist to address such
concerns through effective client education.
Long-term care.  Long-term care staff are often
the agents of change in interventions with patients
who have dementia. As such, they benefit by education in the administration of appropriate assessment
strategies and monitoring of pain levels over time.
Inadequate knowledge of the nature of pain
(e.g., discounting the importance of psychological
components of pain) could lead long-term care staff
to not appreciate (and consequently not adequately
support) integrated pharmacological and psychosocial interventions designed to distract patients from
their pain experience and to improve quality of life.
Knowledge gaps in pain knowledge and education
have been well documented among long-term care
staff (Martin et al., 2005; Zwakhalen et al., 2007)
and nursing curricula do not tend to offer sufficient
geriatric pain education (Watt-Watson et al., 2009).
Certainly, geropsychologists could provide informal

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Pain Assessment and Management in Older Adults

one-on-one pain education. Practitioner-oriented
articles (e.g., Hadjistavropoulos, Dever Fitzgerald, &
Marchildon, 2010) and other training resources
(e.g., Gagnon & Hadjistavropoulos, 2011) exist for
this purpose. Geropsychologists also can conduct
workshops to educate long-term care staff. When
these workshops are conducted in an interactive
fashion, they are effective in imparting pain assessment knowledge (Ghandehari et al., 2013) but central management support (e.g., the establishment of
improved standards for pain assessment and the provision of protected staff time to conduct adequate
pain assessments) typically is needed for long-lasting
change in clinical practices (Gagnon, Hadjistavropoulos, & Williams, 2013).
Education of client (and family) about geropsychological assessment and treatment. 
Interventions with seniors who live independently
in the community.  It is of critical importance for the
clinical geropsychologist to educate clients about
the nature of pain, the critical role of psychological
factors, and the outcomes of psychological interventions. Most clients will easily accept that psychological consequences of chronic pain are frequent
and that these can be managed. Moreover, educating clients about the interconnections of feelings,
thoughts, and behaviors also is important. Like in
all types of psychological talk therapy, adopting a
dialectic approach (as opposed to lecturing to the
client) tends to work best. Using the typical “behavioral experiments” advocated by Beck (1979) and
others is very helpful in that the client is most likely
to be convinced of something experientially rather
than because the therapist said so.
Similarly, education about a wide variety of
treatment options for pain (e.g., physical therapy,
alternative modalities such as acupuncture) is also
important to provide because older adults often
believe that medication is their only option. Myths
about the relationship of pain and aging (discussed
previously) should be addressed, as should the
impact of physiological changes that accompany
aging (e.g., changes in the body’s ability to metabolize medications may result in different prescribed
dosages for older people; age-related changes in
sleep patterns). Finally, encouraging appropriate

communication of pain complaints with others who
can provide care is also important as older people
sometimes avoid communication of their pain out of
concern that they may be pressured to reduce their
independence.
Some literature that would facilitate client and
family education, regarding pain management in
older persons, is available (see Hadjistavropoulos & Hadjistavropoulos, 2008). Multidisciplinary
approaches to pain education, where feasible, would
be ideal because they could incorporate input from
physicians, exercise therapists, and other professionals all of whom would be working together
toward common pain management goals.
Long-term care.  Including families and longterm care residents as much as possible in pain
education and discussion of options for pain management is more than desirable not only because
understanding the nature of pain is important but
also because it opens pathways of communication
that could produce insights about the patients’
experiences. Understanding, for example, that
uncontrolled pain could lead to behavioral disturbance in residents with dementia could facilitate an
understanding of the residents’ behavior and even
reduce caregiver stress that could be the result of
caregiver misattribution of aggressive patient behavior. Family members can become collaborators in
treatment (e.g., by assisting with pleasant activity
scheduling that could distract the patient from the
pain experience).
Geropsychologist–client relationship issues.  Like
any other client, older people ought to be treated
with respect. Advanced empathy skills can facilitate
the building of rapport that would allow for effective intervention. Allowing stereotypic beliefs about
older people to enter the assessment–therapeutic
relationship could result in a lack of openness
that would hinder a thorough understanding of
the older person’s experience. In long-term care in
particular, it has been suggested that as dementia
progresses, patients are viewed as having reduced
personhood (Malloy & Hadjistavropoulos, 2012).
As a result, references such as “the broken hip in
Room 4” suggest that a patient can sometimes be
viewed as an object of care rather than as a unique
individual. As such, it has been recommended
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Thomas Hadjistavropoulos

(Hicks, 2000) that a self-examination of the
health professional may facilitate more authentic
relationships between patients and care providers
(e.g., asking oneself whether or how one reacts
differently when one believes that a patient with
dementia has pain as compared with a patient
without dementia).

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Technical Aspects of Intervention
The most effective treatment approaches for people
with chronic pain tend to be interdisciplinary and
to incorporate a variety of modalities, such as medical, psychological, and physical (Flor, Fydrich, &
Turk, 1992; Nicholas, Wilson, & Goyen, 1992;
Peters, Large, & Elkind, 1992). Working with
other professionals, psychologists can utilize a
variety of approaches focusing on the improved
pain management of the older person. Such
approaches include CBT (reviewed in more detail
later in the next section), psychoeducation, recommendations for self-management programs, support groups, and others. More recently, some
support has begun to emerge for the efficacy of
mindfulness-based approaches for older people
with pain (e.g., Morone, Greco, & Weiner, 2008).
Although a variety of more specific strategies
have been used with success in younger people
(e.g., relaxation therapy, biofeedback), efficacy
evidence with older people is limited (Hadjistavropoulos, Hunter, & Dever Fitzgerald, 2009). As is
the case with most psychological therapies, a dialectic Socratic style with strong empathy skills is
often necessary for therapeutic success.
Controversies.  Numerous controversies are related
to the management of pain (e.g., optimal pharmacological approaches, alternative treatments), but
the focus here is on psychological therapies. The
role of the psychologist as a pain management treatment provider often is dismissed by health professionals who ascribe to biocentric approaches to
pain. And yet such biocentric perspectives fail to
address major challenges of pain control that arise
from poorly understood psychosocial determinants
of the pain experience, disability, and rehabilitation outcomes, including access to necessary care
(Craig & Hadjistavropoulos, 2004). Usually, health
professionals are accepting, however, that a chronic
426

pain patients’ quality of life can improve despite the
pain with psychological assistance. This represents
a common ground upon which psychologists can
work with most health professionals.
As indicated elsewhere in the chapter, considering pain as a “normal” part of aging, which represents a commonly held belief, is not helpful when it
comes to ensuring that older adults have adequate
access to treatment resources. Such beliefs contribute to the undertreatment of pain in this population
(Ferrell et al., 2001; Horgas et al., 2007; Martin
et al., 2005; Morrison & Sui, 2000; Robinson, 2007;
Won et al., 2004).
As is the case with the psychological assessment
of pain, scarce resources and limited funding often
result in psychological services for older adults
with pain taking the back seat to physical interventions. More research on the medical cost offset of
psychological interventions for older people with
pain potentially could play a key role in persuading
policy makers to allocate increased resources to
psychological treatment services.
Evidence-based treatments. 
Cognitive–behavioral therapy.  CBT for chronic
pain is typically a time-limited intervention with
two primary goals: better management of the
patient’s pain and improved quality of life despite
pain. Recognizing the interconnections among
thoughts, feelings, and behaviors, CBT involves
largely four broad categories of therapeutic techniques (Skinner et al., 2012): (a) cognitive techniques (e.g., cognitive restructuring and problem
solving); (b) behavioral techniques (e.g., relaxation training, pacing, and behavioral activation);
(c) supportive techniques (e.g., psychoeducation
and supportive therapy); and (d) a diverse set of
complementary approaches, including but not
limited to biofeedback, relapse, prevention, and
hypnosis. A therapist will use some or all of these
techniques within the context of CBT. Because an
introduction to CBT is beyond the scope of this
chapter, brief discussion of the various categories
of techniques will consist of examples contextualized in the context of the older adult.
The first category includes cognitive techniques.
Examples of the types of maladaptive beliefs
encountered in therapy (along with thoughts that

Pain Assessment and Management in Older Adults

can substitute these through cognitive restructuring)
with older adults include the following:
■■

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■■

“Pain is a normal part of aging that must be
endured” potentially could be substituted with
“Pain is the result of pathology and can be managed regardless of a person’s age.”
“I cannot accomplish anything because I am
in pain” potentially could be substituted with
“Although I am no longer able to do some of the
things that I could do before my chronic pain
problem developed, I still can engage in many
meaningful activities.”

Maladaptive thoughts are tackled using cognitive
restructuring and behavioral experiments (see Case
Examples). For a discussion of cognitive–behavioral
procedures in general, the reader is referred to a
wide variety of specialized texts, such as Managing
Chronic Pain: A Cognitive Behavioral Therapy
Approach (Otis, 2007).
Problem solving, as a cognitive technique, is
aimed to assist client to address problems of daily living. The problem is defined, often broken down into
smaller pieces and then a plan is developed by the client and therapist working together. For example, an
older person who has difficulty communicating with
his or her physician may problem solve with a therapist about finding potential solutions (e.g., preparing
in advance a list of questions for the physician).
The second category of CBT techniques includes
behavioral procedures. A behavioral technique frequently used with older adults with chronic pain is
pacing. Sometimes tasks (e.g., cleaning the house)
may seem difficult to accomplish, as a result of
pain, leading to procrastination. Other times, clients
attempt to do too much at once leading them to
associate a given activity (e.g., house cleaning) with
pain. This results in anxiety and distress in anticipation of such activity. With pacing, the older person
will be encouraged to break down the chore into
small, manageable components. Moreover, he or she
may be instructed to only engage in the housecleaning activity before significant pain elevations
are experienced (e.g., a person who starts to experience pain after 10 min of vacuuming may be encouraged to vacuum for 5 min at a time). This would
lead the pain and the activity to become dissociated

from each other. As such, decreased distress and
anxiety surrounding that activity may result.
Other behavioral strategies include relaxation training (which would be especially indicated for pain
that can be exacerbated by muscle tension) as well
as graded behavioral activation procedures.
The third category of CBT techniques incorporates adjunctive and supportive approaches. Psychoeducation of the older pain patient, for instance, is
critical not only to dispel myths about pain and
aging but also to facilitate an understanding of the
wide variety of treatment options that are available.
Older people frequently are given medication as the
sole treatment, whereas approaches such as physical
therapy, occupational therapy, and massage also can
be helpful. When working within multidisciplinary
teams, all health professionals can contribute to
patient education. Moreover, support is beneficial
for crisis management, pain flare-ups, and other
difficult situations that clients may encounter.
Finally, various complementary approaches are
used in CBT. Relapse prevention (e.g., Ludgate,
2009), for instance, is a key component of therapy.
By the end of treatment, the patient should be
equipped with a variety of tools that can be used to
manage and cope with pain as well as other difficult
situations that may be encountered in the future. As
part of relapse prevention and management, clients
should be prepared to expect setbacks and symptom
fluctuations that are common in people with chronic
health problems. Relapse prevention also helps clients conceptualize such setbacks as a normal part of
the course as opposed to adopting the black-andwhite view that a flare-up means that the time they
spent learning better ways of managing their pain
has gone for waste. Moreover, developing prevention-related coping skills for high-risk (relapse) situations is also an important component of therapy.
As indicated, complementary techniques such as
biofeedback have been used with success in younger
people, but more research is needed to draw firmer
conclusions about efficacy in an older sample.
The efficacy of CBT for chronic pain has been
well documented (Day et al., 2012) with moderate
effect sizes being identified (Butler, Chapman, Forman, & Beck, 2006). Research on the effectiveness
of CBT with older adults also has been conducted
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Thomas Hadjistavropoulos

(e.g., Green, Hadjistavropoulos, Hadjistavropoulos,
Martin, & Sharpe, 2009; Waters, Woodward, & Keefe,
2005), but some benefits seem limited to specific
areas of functioning, such as beliefs about the nature
of pain or pain intensity, rather than in global areas of
improvement. Lunde, Nordhus, and Pallesen (2009)
conducted a meta-analytic investigation of CBT for
chronic pain that specifically focused on older adults.
They concluded that the overall effect size (.47) was
moderate and that there was a demonstrated benefit
on self-reported pain but not on physical function,
depression, and medication use. Note, however, that
the long-term efficacy of CBT for chronic pain is
unknown. More work is needed on the refinement
of CBT interventions for older adults with pain.
Mindfulness-based approaches.  In addition to CBT,
mindfulness approaches (based on principles related to
meditation, focus on breathing, body scan, and placing
attention nonjudgementally to the body) are gaining
in popularity. Some limited data on the effectiveness of
such approaches is beginning to emerge. For example,
Morone et al. (2008) demonstrated that compared with
a control group, older adults who took part in a mindfulness-based intervention program showed improvements with respect to self-reported pain acceptance
and self-reported activities engagement. Qualitative
research (Morone, Lynch, Greco, Tindle, & Weiner,
2008) also suggested benefits of mindfulness meditation in domains such as pain reduction, improved
attention, and improved well-being.
Acceptance and commitment therapy (ACT),
which involves people learning to stay in contact
with emotions and thoughts, also has been gaining
popularity in pain management (e.g., Dahl, Wilson, & Nilsson, 2004; Thorsell et al., 2011; Wetherell et al., 2011). Rather than changing the irrational
focus of negative thoughts, such thoughts are viewed
as targets for exposure. Mindfulness techniques also
are incorporated in ACT. ACT research with older
adults is very limited, but McCracken and Jones
(2012) have provided initial preliminary evidence in
support of the approach for people over 60 years old.
The self-management of pain in older people.  Selfmanagement is a term that has been used loosely
to describe a variety of programs designed to help
patients manage their own symptoms. Approaches
that have been described as self-management d
­ iffer
428

with respect to the extent they rely on support
from a facilitator who is sometimes a health professional. Some approaches, for example, involve
group meetings led by a health professional or a
volunteer (Ersek, Turner, Cain, & Kemp, 2004;
Lefort, Gray-Donald, Rowat, & Jeans, 1998).
Other self-management approaches (e.g., bibliotherapy) do not rely on a facilitator and involve the
use of self-help manuals or other literature (e.g.,
Hadjistavropoulos & Hadjistavropoulos, 2008). Pain
management programs also can be offered through
the Internet (e.g., Rini, Williams, Broderick, & Keefe,
2012) with or without therapist support.
Self-management approaches to a variety of health
conditions, including pain, are gaining in popularity
because demands on the health care system have
been increasing and self-management has the potential to result in cost savings (Wheeler, 2003). Moreover, self-management could reach individuals who
have limited access to health care services (e.g., residing in remote locations, having limited mobility).
Goals of pain self-management involve creating
or maintaining meaningful life roles despite a
person’s pain, dealing with the emotional consequences of pain conditions, and improving medical
management through enhanced adherence with
prescribed therapies (Corbin & Strauss, 1988;
Hadjistavropoulos, 2012; Lorig & Holman, 2003).
Self-management success relies on a variety of core
skills, including problem solving, taking action, and
creating partnerships with health care providers
(Lorig & Holman, 2003). Moreover, patients learn
information, techniques, and skills, such as mood
management approaches and coping strategies, and
they become familiar with a broader set of treatment options (Lorig & Holman, 2003). At the same
time, self-management involves certain risks
(Hadjistavropoulos, 2011), including the potential
of misuse of specific procedures (e.g., in the
absence of health professional supervision, a patient
may perform a physical exercise incorrectly risking
injury). Moreover, compliance with pain management activities may be lower in self-management
because of the absence of accountability associated
with seeing a health professional on a regular basis,
but this is addressed in programs in which health
professional support is available. Results of

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Pain Assessment and Management in Older Adults

self-management of pain in older adults have been
mixed (e.g., Coster & Norman, 2009; Ersek et al.,
2004), although older adults report that they enjoy
learning about pain management strategies (Barefoot,
Hadjistavropoulos, Carleton, & Henry, 2012). Nonetheless, self-management programs specifically focusing on people with arthritis show promise especially
in improving pain (within 1 year) and disability in the
longer term (more than 26 weeks; Du et al., 2011).
Part of the concern with research on self-management programs is that these programs usually are
not standardized and vary across studies. That is,
some self-management programs may be better than
others and, depending on the program used, research
results may vary. As such, it would be important for
the field to aim for an across-studies standardization
of promising self-management programs. Another
consideration is that based on research with conditions other than chronic pain (Newman, Erickson,
Przeworsi, & Dzus, 2009), it is likely that the addition of a health professional facilitator may improve
outcomes (Hadjistavropoulos, 2012).
CLINICAL APPLICATIONS
This section considers contextual influences on
pain. Two case studies also are presented. The first
case study focuses on an older adult long-term care
resident who suffers from dementia. The second
case study describes an independent, communitydwelling senior with chronic pain.

Examination of Socioeconomic Influences
and Other Contextual Issues on Clinical
Application
Cognitive–behavioral pain assessment and management approaches focusing on older people share many
common elements with treatments directed to
younger persons. There are, however, some unique
considerations. In the first instance, the types of
stressors that older people face can be quite different
from those encountered by younger adults. With
younger people, for example, a common focus of CBT
for chronic pain is return-to-work or work-related
functioning, whereas with retired older adults, the
focus tends to be on other stressors (e.g., loneliness
due to both pain and factors, such as widowhood).

Moreover, some of the psychoeducational information
offered to the older adult may be different from that
offered to other people given the physiological and
other changes that occur with age (e.g., changes in
sleep patterns associated with aging; different rates of
metabolizing medication). Finally, CBT for older
adults also will focus on myths around pain and aging
such as the ones reviewed earlier in this chapter.
In instances in which the chronic pain problem
affects mobility, CBT potentially can be offered at
the older adults’ home (e.g., Green et al., 2009), but
this usually is not feasible. Promising CBT treatments also have been offered via the Internet (e.g.,
Brattberg, 2006), although the suitability of these
treatments for older people remains to be studied.
Cross-cultural and gender issues are important.
Most patients with certain types of pain (e.g., rheumatoid arthritis, headache, temporamandibular disorder) are female (Rollman, 2004; Unruh, 1996).
Both biological sex and psychological gender roles
are predictors of pain threshold, tolerance, and pain
unpleasantness. Moreover, clients from certain cultural backgrounds and their families have been found
to be more expressive of their pain (see Rollman,
2004). As Rollman (2004) observed, however, much
of the relevant research has focused on small samples
and the sociocultural groups under investigation
often differ on dimensions other than ethnicity
(e.g., level of education, income). Moreover, it is not
productive to make sweeping statements about pain
reactivity across cultural groups. Instead, the focus
should be on individuals. Nonetheless, it has been
shown that adequate pain management sometimes is
more likely to be offered to members of the majority
culture than to members of other cultural groups,
suggesting disparities in health care (e.g., Sheiner,
Sheiner, Shoham-Vardi, Mazor, & Katz, 1999; Todd,
Samaroo, & Hoffman, 1993). As such, it is important
for psychologists to be attuned to the possibility of
such disparities so that they can facilitate the client
becoming aware of his or her treatment options.

Case Examples Illustrating Assessment
and Intervention
Case example 1: A case illustration of pain assessment in long-term care.  In an article entitled “Pain
429

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Thomas Hadjistavropoulos

Assessment as Intervention,” Fuchs-Lacelle et al.
(2008) demonstrated that regular use of pain assessment in long-term care settings has direct clinical
benefits from patients. Exhibit 16.2 includes detailed
guidelines of how pain assessments should be conducted and interpreted. A specific recommendation is
that assessment should be individualized with the clinician looking for unexpected changes in the patient’s
pattern of scores.
Figure 16.1 shows a diary (based on Misson et al.,
2011) used in a clinical setting to regularly record
PACSLAC pain assessment scores. The scores were
obtained through observations of the nursing staff,
and the diary is based on a male 79-year-old patient
with a diagnosis of Alzheimer’s disease. A recent
MMSE score on the patient was unavailable because
he had been inaccessible for cognitive assessment as a
result of severe cognitive impairment. The geropsychologist’s role in this case was to train the nursing
staff in the appropriate use of observational pain
assessment protocols and to serve as a consultant
(e.g., in the event of behavioral disturbance that often
is associated with pain) in his capacity as a member of
an interdisciplinary team that also included nurses, a
physician, and a physical therapist. The team had
access to consultation with outside professionals
(e.g., a dentist, medical specialists).
As can be observed on the diary in Figure 16.1,
following a period of relative stability in PACSLAC
scores, there was an elevation around August 8. The
elevation was due to an endorsement of pain behaviors, such as grimacing and frowning. Moreover,
restlessness and behavioral disturbance (e.g., aggression) were becoming evident, causing an additional
elevation in the PACSLAC scores. In response to
the change in the pattern of scores and related observation of the patient, the team met and, through
appropriate investigations, determined that the
patient was suffering from an abscessed tooth. Following administration of antibiotic medication, the
pain scores and associated behavioral disturbance
subsided as the tooth infection had been treated.
The next time that an elevation of scores was
observed was around August 25 at which time the
patient had undergone extraction of the tooth that
had abscessed. Following recovery from the tooth
extraction, the pain scores were reduced again.
430

Case example 2: A case illustration of CBT—Martha. 
Referral.  Martha was referred to a psychologist
by her primary care physician who recently received
a brochure announcing psychological services for
people with chronic pain. The referral read: “I am
referring this 72-year-old lady to you because she
feels depressed. She presents with sciatica and her
social network is limited. Please offer her support.”
Brief history.  Martha is a 72-year-old retired
teacher who suffered from back pain associated with
sciatica. When Martha was younger, she and her
husband were very active both socially and physically. One of her greatest pleasures was her bridge
club that got together at least once a week for merriment and bridge. This changed over the past decade,
Martha has been unable to organize the gatherings
due to increased pain and her husband’s passing.
Over time, the group stopped meeting.
Martha’s 40-year-old son is a computer company
executive and moved to Vancouver where he lives
with his young family. Martha’s 42-year-old daughter works for a publishing house in Winnipeg, Manitoba. With her family away, Martha has been feeling
increasingly isolated. Because of her pain condition,
she became reluctant to attend social activities and,
gradually, as a result of increased social isolation,
she begun to feel lonely and depressed.
On the advice on her health professional, she
had been attempting to manage her pain with overthe-counter medication and had not been very successful. Martha, had a limited understanding of her
condition and was not aware of all treatment
options. She felt that she had limited time with her
physician and, as a result, was not able to get her
questions answered. She had been encouraged to
endure her pain “because it is normal for an older
person to have aches and pain.” Finally, she felt
frustrated for not being able to complete many
chores (e.g., house cleaning) because of pain. In
fact, she would sometimes let chores pile up
(because she avoided them since they had become
associated with pain) and then, when they absolutely had to be done, she would do too much at
once, exacerbating her pain and suffering for several
days after. As Martha put it, she “felt like a failure.”
Initial assessment.  Initial assessment consisted
of a clinical interview, the BPI (Cleeland & Ryan,

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Pain Assessment and Management in Older Adults

1994), the GDS (Yesavage et al., 1982), and the CSQ
(Rosenstiel & Keefe, 1983). Martha’s BPI responses
were consistent with moderate pain and with moderate to severe pain-related interference with daily
activities as well as mood deflation. Scores on the
CSQ revealed elevations in the catastrophizing subscale, indicating the presence of catastrophic thinking about pain (which often is seen among patients
with mood deflation), and an unusually low score
on the active behavioral coping subscale. Her score
on the GDS fell within the depressed range. The
clinical interview confirmed the presence of depression, including hopelessness as well as social isolation. Martha also expressed inability to complete her
daily chores because of her pain and noted that her
not completing such chores tended to exacerbate
her mood deflation. The need for pain education
also became evident as Martha was unaware of the
potential impact of psychological and social factors
on the pain experience.
Psychoeducation.  Psychoeducation focused on
variety of topics, including the interplay of psychological and physical factors in the pain experience;
myths related to pain and aging; and the relationship
among thinking, behavior, and emotion.
Treatment plan.  To provide Martha with
improved pain management and quality of life,
cognitive–behavioral procedures were planned.
Specifically, catastrophic thinking and other maladaptive beliefs about pain would be tackled through
cognitive restructuring, while careful pacing and
behavioral activation would aim to allow Martha to
gradually resume a more productive day-to-day life.
Through improved social engagement and ability
to examine her thinking, it was anticipated that her
mood would improve. Adjunctive strategies, such
as relaxation training, also were planned. A brief
description of this plan, with Martha’s consent, was
sent to her physician who was encouraged to contact
the psychologist with any questions or concerns.
Process and outcomes.  Martha felt quite confused and, perhaps somewhat defensive, about having been referred for psychological therapy. Early
during the first session she said, “I don’t know why
my doctor referred me to you. I’m not crazy!” The
psychologist, Dr. Better, well aware that CBT for
chronic pain has two primary goals (i.e., to reduce

pain intensity and to improve one’s quality of life
despite the pain) chose to focus his explanation on
the second primary goal. He asked Martha how her
pain made her feel. Through discussion, it became
clear that Martha felt frustrated, upset, and angry
during pain exacerbations. As a result of these emotions, she tended to become more pain focused
and, consequently, found the pain more difficult
to handle. She was able to accept this conceptualization (i.e., the vicious cycle of pain → negative
emotion → increased focus on pain → pain feeling
increasingly of overwhelming) and agreed to try
and see whether the sessions would help her feel
better, from a psychological standpoint, despite the
pain. A therapeutic alliance had begun to develop
and Martha agreed to 10 sessions of therapy with
the understanding that the therapeutic contract was
subject to alteration and that progress would be
reviewed after the fifth session.
In the weeks that followed, several issues were
addressed. Through cognitive-restructuring procedures, Martha begun to recognize that pain is not a
natural part of growing old and that it is important
to manage it regardless of a person’s age. She also
learned about treatment options and problem-solved
about her concern that her physician did not have
enough time to answer her questions. Role-plays
took place in the session to give Martha the opportunity to practice appropriate assertiveness skills
that she used successfully in interactions with health
professionals. As a result of better understanding of
her treatment options and her assertiveness, her
physician referred her for physical therapy, which
she found to be helpful in the management of her
condition. She also practiced various relaxation
procedures.
A primary concern and source of stress for Martha was the association of household chores and
pain (and related procrastination). Martha was
encouraged to break each challenging chore into
smaller components that could be completed in a
gradual fashion. Through exploration, Martha
acknowledged that vacuuming was one of the most
discomforting routine chores, although she could
vacuum for 10 min before experiencing pain. In an
effort to break the association between pain and
vacuuming, she was encouraged to initially vacuum
431

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Thomas Hadjistavropoulos

for 5 min at a time while monitoring her pain levels
in a diary. Gradually vacuuming became less anxiety
provoking (and thus less likely to be avoided)
because it was no longer associated with pain.
Through such pacing approaches, Martha learned to
complete her chores gradually and comfortably.
When her social isolation was tackled, Martha
pointed out that her husband passed away and her
children had moved. She also said that she had few
social connections, and it was difficult for her to
make new friends “because people have their own
lives and would not be interested in talking to her.”
She agreed to engage in a “behavioral experiment”
to check out her belief that people would not want
to talk to her. Specifically, she joined a knitting club
at a local seniors’ center. Initially she was concerned
that she would be disruptive because she could not
sit for very long but, by testing out her beliefs, she
discovered that she developed new social relationships (including with a woman who was an old
acquaintance and who happened to be a member of
the same club; the two begun to go for coffee
together on a regular basis initially before class and
then weekly). Her depression-related beliefs (e.g.,
“I am a failure”) were tackled through cognitive
restructuring and behavioral assignments. Indeed,
Martha had accomplished a lot in her life. She had
come from a poor family and put herself through
university. She then became a successful and
sought-out teacher and raised two great kids. She
then took care of her ailing husband during the last
2 years of his life, something for which he had been
very grateful.
Around Session 9, the therapeutic contract was
renewed for an additional five sessions, as Martha
found the treatment beneficial. The last few sessions
focused on relapse prevention and on ensuring that
Martha was prepared to anticipate the normal ups
and downs that people with chronic conditions tend
to experience. At the time of discharge from treatment, her self-reported pain levels and pain-related
interference had been reduced to a mild–moderate
level, her GDS score fell within the normal range,
and the CSQ catastrophizing subscale elevation was
reduced to a level that was consistent with norms
for her age-group. The active behavioral coping CSQ
subscale score was somewhat increased, although
432

there was still room for improvement. With an
expanded social network, better pain management,
an adaptive approach to pacing, and the ability to
examine the evidence for the validity of distressing
thoughts, Martha was no longer feeling depressed
nor was she isolated. As Martha put it during the
last session: “I have so much to look forward to. I’m
grateful for what I have and I can’t wait to visit my
son in Vancouver and to catch a cruise to Alaska
this summer.”
FUTURE DIRECTIONS
This section considers the role of the clinical geropsychologist in pain assessment and management.
Future directions for research and clinical application also are discussed.

Role of the Geropsychologist
The reality remains that despite demonstrated benefits in the role of the geropsychologist in pain management and assessment, the majority of older
chronic pain sufferers do not have access to such
expertise. Through advocacy and education of both
health professionals and policy makers, it is hoped
that more older adults will benefit from such care
both in the community as well as in health care
facilities (i.e., both long-term and acute care).

Next Steps in Research and Clinical
Application
Despite advances in the area of pain assessment
in older adults, more remains to be done. Translations of existing assessment tools in languages
other than English (e.g., Basler et al., 2006;
Santos, Castro-­Caldas, & Hadjistavropoulos, 2012;
Zwakhalen et al., 2006) have begun to emerge,
but more foreign language validation is needed.
Moreover, appropriate normative information
(for seniors within and outside long-term care)
on formalized tools used in pain assessment is
limited. In the cases of people with dementia,
more research is needed to evaluate the specificity
of existing assessment methodologies. That is,
it would be important to establish that these
methods can discriminate pain from other
distress states that are not pain related.

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Pain Assessment and Management in Older Adults

In long-term care facilities, both resource limitations and inadequate staff pain education prevent
implementation of potentially beneficial protocols
for pain patients. Education gaps can be addressed
with effective pain education (e.g., Ghandehari et al.,
2013), but central management support often is
needed for the permanent implementation of effective protocols (Gagnon et al., 2013). Geropsychologists can play a key role in pain education, given the
psychological sequelae of pain as well as the psychological components of the experience itself. Proficient in behavioral assessment, psychologists can
provide appropriate pain assessment education.
With respect to intervention, much more needs to
be done to reach older people who live in remote
areas or who have limited mobility. Psychological
interventions as well as assessment can be administered effectively via the Internet but not enough evaluations of Internet-administered pain management
interventions have been conducted with older people.

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